CDC Ebola Response Oral History Project The Reminiscences of Joel M. Montgomery David J. Sencer CDC Museum Centers for Disease Control and Prevention 2016 Montgomery – 2 – 1 Joel M. Montgomery Interviewed by Sam Robson May 10th, 2016 Atlanta, Georgia Interview 2 of 2 CDC Ebola Response Oral History Project Q: This is Sam Robson here with Dr. Joel Montgomery. Today’s date is May 10th, 2016, and we’re here in the audio recording studio at CDC’s [Centers for Disease Control and Prevention] Roybal Campus in Atlanta, Georgia. I’m interviewing Joel as part of the Ebola [Response] Oral History Project. It’s our second interview. Our first one, we covered Joel’s life and career up through basically his work in Viral Special Pathogens [Branch], coming out of EIS [Epidemic Intelligence Service]. Today we’ll be digging into his experience with the West African Ebola response. But first, actually, Joel, I wanted to ask you if you could briefly summarize the work that you did in Peru and Kenya previous to this response. Montgomery: Sure. I guess I’ll start with Peru and go forward. The work in Peru, I think it was 2006 that I went to Peru, and we were there for five years. I was actually there, it was a collaboration with the US Navy, which at the time it was Naval Medical Resource Center Detachment, now it’s called the Naval Medical Research Unit 6. It became a “full command,” to use Navy lingo. But I was there actually funded by the Influenza Division. At the time, it was organized completely differently than it is now, as you can imagine, the flu division. In fact, I think at the time it may still have been the flu branch. It was much smaller. This was really pre-H5N1 and all that, obviously. Montgomery – 2 – 2 I was out there with the US Navy, and my role out there was leading their emerging infections program. We spent five years in Peru, I was there with my family. At the time we moved out, it was my wife and my son, Van, our son, Van. But I ran their emerging infections program, and we worked on a number of different diseases, including influenza. Working throughout Peru, but from the Amazon to the Andes to the coast. Doing a lot of work on influenza and other respiratory diseases, but we worked on other pathogens like rabies, and you name it. Anything that popped up, dengue, we would work on it. But we also did a fair bit of work in Bolivia, in Paraguay, in Ecuador, and throughout the region, all the way up into Central America, we were doing some work on surveillance, capacity-building training. I, again, ran their emerging infections program and built up the program they had. Hired basically Peruvian staff, epidemiologists, physicians, veterinarians, laboratorians, and staffed up that program. Again, was there for five years. Q: Okay, and how about Kenya? Montgomery: Kenya, we went straight from Peru to Kenya. We arrived in Kenya in—I think it was probably August of 2011, and we were there for four years. So back in August, 2015. My role there was also running their emerging infections program, very similar platform, but restricted more to really just Kenya, so most of our work was in Kenya. Although we did launch a few projects in Tanzania and we did some outbreak Montgomery – 2 – 3 response in Ethiopia, and some work indirectly in Somalia. But I ran their emerging infections program. Again, it was really a similar focus as what we had in Peru, so looking at burden of disease, what are the causes of the burden of disease, what’s the etiology, and evaluating interventions. My role there actually evolved over time. When I first arrived, I was head of their emerging infections program, and then became the Global Disease Detection division director. The structure of the Kenya country office also evolved over time. Eventually, Kevin [M.] De Cock came back from Center for Global Health. He was the director here of CGH [Center for Global Health] for a few years. He came back to Kenya, became the country director, and he ended up making me his principle deputy. It was a fair bit of additional administrative responsibility. I would say I moved out of being a scientist to be more of an administrator. He traveled quite a bit too, so I ended up being acting country director quite a bit when he was on travel. It was a bit more of a role of responsibility over time. But it was fine. It was a good experience. Obviously, learned a wealth of information from Kevin. He’s a good mentor, a good leader. Q: Do I have it right that you were focusing, to at least some extent, on children under five? Montgomery: Yeah, we did. We had two big population-based surveillance sites—one in Kibera, one of the largest slums in East Africa, following a population of about thirty thousand people with an associated clinic. Then we had a sister site in western Kenya. So Montgomery – 2 – 4 really looking at differences in disease transmission and burden in urban versus rural sites. A lot of it was children under five, big percentage of the population that we were following were children, and children specifically under five because that’s where you see the heaviest burden of respiratory and diarrheal disease. Then, of course, because we had these two clinics that we were working with and partially funding, the healthcare was free, so a lot of the moms would bring their children in for free health care at these clinics. It was really understanding what the burden of disease and etiology of disease was and is in children under five, with an eye towards implementing and evaluating interventions, be those pharmaceutical interventions like vaccines, or drug interventions, or non-pharmaceutical like water sanitation, education, these sorts of interventions. That’s really what it was. It was an eye towards intervention and leading to, ultimately, policy change in the Ministry of Health in the government of Kenya. Some examples of that, we were very engaged with the flu division, and they had a vaccine clinical trial, a demonstration project in Kibera. Then, because it was so successful and we actually demonstrated a reduction in flu burden, the government eventually adopted a vaccine policy. It’s still being developed and in process, but it at least got them thinking that flu is actually a legitimate cause of respiratory illness in the populations of Kenya. Before that, they really thought flu is not a problem here, but it’s a significant burden. That was just one example. Another example is really looking at typhoid fever, Salmonella typhi, and the cause of typhoid fever. Again, up to this point where we had done the studies in Kenya, typhoid Montgomery – 2 – 5 was really not thought to be a problem in Africa, but really areas like Asia and the Asian subcontinent. But in fact, we did demonstrate heavy burden of typhoid fever. There’s a vaccine for typhoid, so at some point, we hope that the country will consider that a major cause of fever and illness in children under five, and will adopt a vaccine strategy. But right now they don’t. Q: Thank you. I remember, and correct me if I’m wrong a little bit. I think in 2012 there were Ebola outbreaks maybe both in DRC [Democratic Republic of the Congo] and Uganda, or maybe one of them was Marburg. I can’t remember. Montgomery: Yeah, there was a Marburg outbreak, it was probably 2012 in Uganda. I forget exactly where in Uganda. Q: Were you involved in that at all? Montgomery: No, we weren’t involved in that, because the Viral Special Pathogens Branch has a fairly robust activity in Uganda in laboratory capability plus response activities. So we didn’t—we were there. In fact, there was, during that outbreak, we had a couple of suspect cases in Nairobi. In fact, I recall one day we did get a call from Kenyatta National Hospital and the Ministry of Health, and they said they had a female that came in from a local—she actually was, I think, a hotel worker, in downtown Nairobi. She developed fever, hemorrhagic manifestations. Of course, everyone knew of Montgomery – 2 – 6 the outbreak that was going on in Uganda. They panicked. Put her in a cab, brought her over to Kenyatta National Hospital. Unfortunately, she died on the way over. It was myself and another colleague of mine and one of our Kenyan colleagues, we suited up to collect a sample to test her. She ended up being negative. Nonetheless, it actually pointed out a weak link in their system: one suspect case of Marburg, they panicked. The hospital, no one in the infection control unit would even go near this body. It caused a huge problem and highlighted an extreme weakness and limitation in their response capabilities and training in infection control. But no, I was not involved in the actual response in Uganda. Q: Okay. Just briefly, do you know if they were able to address those shortcomings in any way, so far? I know that’s still in the recent past. Montgomery: It certainly has improved because of a couple of reasons: one, the West African outbreak. Obviously, everyone now has heightened awareness and preparedness. Then I think the Global Health Security Agenda has also helped contribute to the preparedness.